In Jessica U. v. Health Care Service Corp., No. CV 18-05-H-CCL, 2020 WL 6504437 (D. Mont. Nov. 5, 2020), the court considered the residential treatment of Jessica, a 16-year-old with a long history of medical and mental health conditions. Jessica had a complicated history of gastric distress and illness which preceded her residential treatment by at least four years. She had her gall bladder removed and multiple endoscopies. She was diagnosed with collagenous gastritis and suffered constant nausea. When Jessica was prescribed prednisone, she gained 20 pounds in a short period of time which was highly distressing to her. Her eating disorder behaviors steadily increased from that point. She then had a gastric pacemaker placed, followed by a Jpeg feeding tube. Jessica refused to eat with the feeding tube.
Jessica was admitted to residential treatment which was focused on the “interwoven nature of Jessica’s physiological health/gastric issues and her eating disorder” and her family’s concept of Jessica as chronically ill. Blue Cross initially approved benefits for residential treatment and then approved benefits when Jessica transitioned to partial hospitalization. However, in June 2015, Jessica’s condition deteriorated during a one-week home pass and upon return to treatment, she self-harmed. Jessica was admitted back to residential treatment, but this time Blue Cross denied benefits claiming that based on the Milliman Care Guidelines (“MCG”), medical necessity was not met.
The court found that the MCG are not referenced or incorporated into the Plan. The Plan defines medical necessity as “in accordance with generally accepted standards of medical practice.” The court found problems with Blue Cross’s claims that the Guidelines were just a tool for administrators to evaluate Jessica’s case and that the MCG encompass generally accepted standards of care. The court found the “record reveals something different” than Blue Cross’s position. The court noted that of the 32 articles cited by MCG, not one specifically addresses eating disorders.
The court relied on caselaw which held that the MCG are “by no means the sole measure of medical necessity.” The court found that “it was precisely due to the acute and imminent factors outlined in the MCG, and relied upon” by Blue Cross that resulted in many of the factors regarding Jessica’s treatment and struggles not considered by Blue Cross. Conversely, Blue Cross applied factors which “had absolutely no relation to her unique mental health issues.” For example, Blue Cross concedes Jessica was never a danger to others, but this factor was repeatedly cited in Blue Cross’s denials. The court found Blue Cross’s “rigid application of the MCG” precluded consideration of factors such as Jessica’s family structure, difficulty adjusting to her meal plan, phobia of attending school, and caring for herself adequately.
The court found that Jessica’s treatment team “were in the best position to make credible recommendations regarding the medical necessity of her residential treatment.” Under a de novo review, the court concludes the MCG should not have been applied and that once disregarded, the evidence demonstrated that Jessica’s residential treatment was medically necessary.
The court also determined that the out-of-network provider should be compensated equal to the payment Blue Cross would make if the services had been obtained within the Blue Cross and Blue Shield of Montana service area. The court ordered Blue Cross to pay benefits due to Jessica for residential treatment.
Jessica U. is represented by Kantor & Kantor, LLP Partner, Elizabeth Green.
If you or someone you know is suffering from an eating disorder and you are being denied benefits by your insurance provider, please call Kantor & Kantor for a free consultation at 800-446-7529 or use our online contact form. We understand, and we can help.